Remote Prior Authorization, RN – Colorado

Job Overview

  • Clinical License RN
  • State(s) CO

Are you looking to work for a company that has been recognized for over a decade as a Top Place to Work? Apply today to become a part of a company that continues to commit to putting our employees first.

 

Job Description:

Position Summary:

The Prior Authorization, Nurse is responsible for clinical review of requests for health care services.

 

Essential Functions:

  • Assesses appropriateness of service requests based on established Medicare and Health Plan standards and guidelines
  • Evaluates the requested care needs of the PHP member using clinical judgement and critical thinking skills
  • Supports physicians and providers in maintaining a focus on quality care enforcement for the Physician Health Partners members
  • Participates in identifying issues related to the prior authorization process and seeks creative solutions to resolve issues
  • Collaborates with team members to ensure incoming service requests are managed within allotted processing time and Medicare required turn-around time
  • Identifies potential need for interdisciplinary collaboration and facilitates referrals as needed
  • Documents service request review activity in a clear, concise, and accurate manner consistent with the internal review processing rules
  • Maintains confidentiality and ensures compliance with HIPAA regulations
  • Other duties as assigned

 

Knowledge, Skills and Abilities:

  • Strong clinical knowledge and critical thinking skills
  • Knowledge of Prior Auth process, NCQA guidelines, CMS – Medicare regulations, HMO Product structure rules and referral requirements
  • Excellent verbal and written communication skills
  • Great customer relation skills
  • Team focused with strong collaborative skills
  • Independent problem-solving skills
  • Self-motivated and self-managed
  • Proficient in Microsoft Office Suite

 

Qualifications:

  • RN with valid license in good standing
  • 3-5 years clinical nursing experience required
    • Previous utilization management, case management or discharge planning experience preferred
  • Experience with Microsoft Excel and Microsoft Teams (preferred)
  • Home office that is HIPAA compliant for all remote or telecommuting positions as outlined by the company policies and procedures.

 

Salary Range:

$65,711 – $82,139

 

 

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